Spine
Spine and
and Spinal
Spinal Cord
Cord
Trauma
Trauma
Objectives of Learning
Describe the basic spinal anatomy and
physiology
Evaluate a patient with suspected spinal
injury
Identify the common types of spinal injuries
and their X-ray features.
Appropriately manage the spinal-injured
patient during the first hour from injury.
Determine the appropriate disposition of the
patient with spine trauma.
Introduction
Vertebral column injury, with or without neurological
deficits, must always be sought and excluded in a
patient with
Multiple trauma.
Any injury above the clavicle
Spine injury
Cervical spine 55%
Thoracic spine 15%
Thoracolumbar junction 15%
Lumboscaral spine 15%
Beware
Excessive manipulation and inadequate
immobilization of a patient with a spinal
cord injury can cause additional
neurological damage and worsen the
patient’s outcome
Introduction
As long as the patient’s spine is protected,
evaluation of the spine and exclusion of
spine injury may be safely deferred,
especially in the presence of systemic
instability.
Every patient with spine injury should be log-
rolled every 2 hours, while maintaining the
integrity of the spine, to reduce the risk of
decubitus ulcer formation.
Log rolling
Anatomy & Physiology
The spinal column
The spinal column consists of 7 cervical, 12
thoracic, and 5 lumbar vertebrae as well as the
sacrum and the coccyx.
For many reasons, the cervical spine is most
vulnerable to injury
The thoracolumbar junction is a fulcrum between
the inflexible thoracic region and the stronger
lumbar levels. This makes it more vulnerable to
injury, with 15% of all spinal injuries occurring in
this region.
Spinal Cord Anatomy
Spinal cord ends at L1
Three tracts can be readily assessed clinically.
The corticospinal tract
The spinothalamic Tract
The posterior columns
If there is no demonstrable sensory or motor function
below a certain level, this is referred to as a complete
spinal cord injury.
If any motor or sensory function remains, this is an
incomplete injury and the prognosis for recovery is
significantly better.
Sparing of sensation in the perianal region (sacral
sparing) may be the only sign of residual function.
Sensory Examination
A dermatome is the area of skin
innervated by the sensory axons
within a particular segmental
nerve root. They are important
to determine level of injury
The key sensory points are
C-5----Area over the deltoid
C-6----Thumb
C-7---- Middle finger
C-8---- Little finger
T-4---- Nipple
T-8---- Xiphisternum
T-10--- Umbilicus
T-12--- Symphysis
L-4----- Medial aspect of the leg
L-5----- Space between the first and
second toes
S-1----- Lateral border of the foot
S-3----- Ischial tuberosity area
S-4 --5---- Perianal region
Myotomes The important key
muscle (s) are.
C-5-----Deltoid
For the sake of simplicity, C-6-----Wrist extensors
certain muscles or C-7-----Elbow extensors
muscle groups are C-8-----Finger flexors to
identified as representing the middle finger
a single spinal nerve T-1-----Smalll finger
segment. abductors
In addition to bilateral L-2----- Hip flexors
testing of these muscles, L-3------Knee extensors
the external anal L-4----- Ankle dorsiflexors
sphincter should be L-5----- Long toe
tested by digital extensors
examination. S-1-----Ankle plantar
flexors
Nerurogenic Shock vs Spinal Shock
Neurogenic shock results from impairment of
the descending sympathetic pathways in the
spinal cord resulting in loss of vasomotor tone
and loss of sympathetic innervation to the
heart
The result is
Hypotension
Bradycardic
Management of Nerurogenic Shock
The blood pressure can often be restored
by the judicious use of vasopressors, but
adequate perfusuon may be maintained
without normalizing the blood pressure.
Atropine may be used to counteract
hemodynamically significant bradycardia.
Spinal Shock
This refers to the flaccidity and loss of
reflexes seen after spinal cord injury. The
“Shock” to the injured cord may make it
appear completely functionless, although
all areas are not necessarily destroyed.
The duration of this state is variable.
Effect on other Organ Systems
Hypoventilation due to the paralysis of,
Intercostal
muscles
Diaphragm
The inability to perceive pain may mask
a potentially serious injury elsewhere in
the body, such as the usual signs of an
acute abdomen
Classifications of Spinal cord Injuries
Level
Determination of the level of injury on both sides is
important.
Injury above the T-1 level-------quadriplegia
Injury Below the T-1 level------- paraplegia
Apart from the initial management to stabilize the
bony injury, all subsequent descriptions of the
level of injury are based on the neurologic level.
Severity of the Neurologic Deficit
Incomplete paraplegia
Complete paraplegia
Incomplete quadriplegia
Complete quadriplegia
Signs of incomplete injury may include:
Any sensation ( including position sense) or
voluntary movement in the lower extremities.
Sacral sparing
Morphology
Spinal injuries can be described as,
Fractures
Fracture dislocations
SCIWORA
Penetrating injuries
All injuries can stable or unstable
All patients with x-ray evidence of injury and all those
with neurologic deficits should be considered to have
an unstable spinal injury.
Specific Types of Spinal Injuries
Cervical spine injuries can result from
Axial loading
Flexion
Extension
Rotation
Lateral bending
Distraction
Specific Types of Spinal Injuries
Atlanto-occipital
Dislocation
Atlas Fracture (C-1)
C-1 Rotary Subluxation
Axis (C-2) Fractures
Odontoid fracturres
Posterior element
fractures of C-2
Fractures and
Dislocation (C-3
through C-7)
Specific Types of Spinal Injuries
Thoracic Spine Fractured ( T-1 Through
T-10)
Thoracolumbar Junction Fractures
( T-11 through L-1)
Lumbar Fractures
Penetrating Injuries
X-Ray evaluation
Cervical Spine
A lateral cervical spine film should be
obtained, when indicated, soon after life
threatening problems are identified and
controlled.
Swimmer’s view
Open-mouth odontoid view / Oblique view
of the odontoid process
X-Ray evaluation
Thoracic and lumbar spine
A.Pfilms
CT Scanning
General Management
Immobilization
Remember to immobilize until c – spine injury is
excluded
Intravenous fluids
Patients with hypovolemia may not become
tachycardiac (may be bradycardiac)
Medications
In North America methyprednisolone is given
Transfer
Guidelines for screening patients with
suspected Injury
The presence of paraplegia or quadriplegia is
presumptive evidence of spinal instability
Patients who are awake, alert, sober, and
neurologically normal, and have no neck pain
are extremely unlikely to have an acute c-
spine fracture / subluxation.
Patients who are awake and alert, are
neurologically normal, but do have neck pain
should undergo lateral, AP, and open-mouth
x-rays of the c-spine.
Guidelines for screening patients with
suspected Injury
Patients who are comatose, have an
altered level of consciousness, or are
too young to describe their symptoms
should at least have a lateral and AP c-
spine x-ray
When in doubt, leave the collar on
Backboards
Never force the neck
Guidelines for screening patients with
suspected Injury
Assess the c-spine film for
Bony deformity
Fracture of the vertebral body or processes
Loss of alignment of the posterior aspect of the
vertebral bodies (anterior extent of the vertebral
canal
Increased distances between the spinous
processes at one level
Narrowing of the vertebral canal
Increased prevertebral soft-tissue space
Summary
Attend to life-threatening injuries, minimizing
any movement of the spinal column
Establish and maintain proper immobilization
of the patient until vertebral fractures or
spinal cord injuries have been excluded
Obtain a lateral c-spine x-ray, when
indicated, as soon as life-threatening injuries
are controlled
Document the patient’s history and physical
examination so as to establish a baseline for
any changes in the patient’s neurologic
status.
Summary
Obtain early consultation with a
neurosurgeon and /or an orthopedic
surgeon whenever a spinal injury is
suspected or detected.
Transfer patients with vertebral
fractures or spinal cord injury to a
definitive-care facility
